Provider Demographics
NPI:1588650527
Name:JOHNSON, JEFFREY DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DEAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 COBB ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2588
Mailing Address - Country:US
Mailing Address - Phone:231-876-6527
Mailing Address - Fax:231-876-6519
Practice Address - Street 1:11 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:MI
Practice Address - Zip Code:49327-7900
Practice Address - Country:US
Practice Address - Phone:231-834-0444
Practice Address - Fax:231-834-0200
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068529207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0804108642OtherBLUE CROSS BLUE SHIELD
MI0N30400Medicare ID - Type Unspecified
MIG90863Medicare UPIN